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| CASE REPORT |
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| Year : 2020 | Volume
: 52
| Issue : 2 | Page : 56-60 |
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Rehabilitation in congenital muscular torticollis operated with Z-plasty: A case report
Vanashree Chandrashekhar Nalawade
Department of Occupational Therapy, D. Y. Patil School of Occupational Therapy, Navi Mumbai, Maharashtra, India
| Date of Submission | 20-Mar-2020 |
| Date of Decision | 30-Mar-2020 |
| Date of Acceptance | 27-Apr-2020 |
| Date of Web Publication | 6-Jun-2020 |
Correspondence Address:
Dr. Vanashree Chandrashekhar Nalawade
402/B Wing, Sparsh CHS Ltd., Bhingar Road, Shedung, Raigad, Panvel - 410 206, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijoth.ijoth_8_20
Among the musculoskeletal congenital anomalies, congenital muscular torticollis (CMT) is the third most common. This condition presents with fibrosis of sternocleidomastoid muscle with increased lateral flexion on the same side and rotation on the opposite side. The objectives of the study were to reduce cervical deformity, mild facial asymmetry and to improve the range of motion of cervical lateral flexion and rotation. A 5-year-old female child had right torticollis for which she underwent Z-plasty. Evaluations were done on preoperative, postoperative day 1, 1 month, 4 months, and 7 months. Rehabilitation techniques included gradual stretching of the sternocleidomastoid muscle, splintage (static serial), positioning techniques, and play activities. Outcome measures observed were significant improvement in the posture of head tilt, range of motion using cervical goniometer, and facial asymmetry using photographs. This case report describes the importance of multidisciplinary treatment approach involving surgery, exercise therapy, play, and customized static serial splinting in the rehabilitation of CMT.
Keywords: Congenital Muscular Torticollis, Rehabilitation, Splintage, Z-Plasty
How to cite this article:
Nalawade VC. Rehabilitation in congenital muscular torticollis operated with Z-plasty: A case report. Indian J Occup Ther 2020;52:56-60 |
| Introduction | |  |
Among the musculoskeletal congenital anomalies, congenital muscular torticollis (CMT) is the third most common.[1],[2],[3] It often presents with fibrosis of sternocleidomastoid muscle, the facial asymmetry with increased lateral flexion on the same side and rotation on the opposite side.[1] In the children above 1 year of age, surgical release of the tight sternocleidomastoid muscle is indicated along with aggressive therapy and appropriate splinting.[1] Occupational therapy rehabilitation in CMT concentrates on observation, orthosis, gentle stretching, myofascial release techniques, parents' counseling-training, and home exercise program.[2],[4],[5],[6] This treatment protocol aimed to reduce the head tilt and facial asymmetry using these rehabilitation techniques.
| Case Report | | |
A 5-year-old female child diagnosed with CMT, had right torticollis when she visited the occupational therapy outpatient department. Her head was tilted toward the right, and she was facing difficulty in rotating toward the right side. Her mother noticed it when she was 6 months but avoided medical treatment. However, she claimed to have performed some exercises and neck stretches at home.
Clinical Findings
Physical examination revealed raised shoulder and shortened neck on the right side, head tilt on the right side, and chin lift toward the left side [Figure 1]. Sternocleidomastoid on the right side was short, firm, and nontender with no palpable lump. Facial asymmetry was seen in the form of mild flattening of the cheek on the right side. Birth history stated no complications.
Based on the examination details, to correct the deformity and facial asymmetry, various treatment approaches were planned involving surgery and rehabilitation.
Timeline
Evaluations and treatment sessions are briefly outlined in [Table 1].
Assessment
Using cervical goniometer, two parameters were measured [Table 2]: | Table 2: Measurement of Posture of Head Tilt and Cervical Range of Motion of Lateral Flexion and Rotation
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- Posture of head tilt - Child sitting on stool and cervical goniometer placed on her head. Without any passive correction, readings noted on the goniometer on the forehead as 20° lateral flexion tilt to the right side and the one on the top of the head (parietal bone) as 15° rotational tilt to the left on the first session
- Passive range of motion of cervical lateral flexion and rotation - Similar to above positioning of the child and cervical goniometer. Therapist moved child's head passively in lateral flexion and rotation to both the right and left side and documented the ranges seen on goniometers[7]
- Facial asymmetry - Change in facial asymmetry was assessed with photographs [Figure 1], [Figure 2], [Figure 3] taken at each follow-ups, therapist compared and documented improvement in mild flattening on the right side of the cheek.[2],[8]
Expected Outcomes
Reduction in the posture of cervical lateral flexion and rotation (head tilt).
Improvement in the range of motion of cervical lateral flexion and rotation.
Improvement in the facial asymmetry (correction of mild flattening on the right cheek).
Intervention
Surgical details
Inferior Z-plasty was planned. Indications for surgery were a persistent head tilt and difficulty with passive rotation. Under general anesthesia, a horizontal incision 1–2 cm above the medial third of the clavicle was performed. The clavicular head was released, and the sternal head was lengthened using Z-plasty while preserving the normal neck contour.[1]
Splint
The therapist preferred to use customized serial static neck splint over Philadelphia collar or four post collar for treatment. It has the properties of low-load prolonged stretch, snuggly fit, perfect contouring, and it can be modified regularly, which helped to keep the head neutral or overstretched toward the unaffected side. It was molded on the affected side, covering around one-third of the face posterolaterally [Figure 2]. Splint position and regimen have been described in [Table 1]. While remolding splint intraoperatively, her face and head were covered with thick gauze, especially over the surgical site (dynaplast dressing) to prevent any pressure sore postanesthesia.
Rehabilitation
The exercise regimen has been described in [Table 1].
Passive stretching exercises included (1) right-left linear movements of the head with the child in supine and head at the edge of the table and (2) gravity-assisted stretching of the right lateral flexors of the neck with the child in side lying on the left side and head at the edge of the bed.[2],[9]
For strengthening cervical flexors, left lateral neck flexors, right rotators, and scapula musculature, therapeutic activities such as peg transfers and ball throwing at different targets were used.[7]
Positioning techniques like carrying a child on caregiver's right side to have child lean on to the left side, sleeping pattern in the prone position with head rotated toward the right were explained to child's parents.
Follow-ups and Outcomes
Postoperatively, no exercises were given till 3 weeks after which gradual return to the preoperative rehabilitation program initiated. After a month, the child was discharged, and the exercise program continued at home.
After 4 months, the child achieved a full range of motion of cervical lateral flexion and rotation. Hence, duration of splint was reduced. After 7 months, deformities such as cervical deformity and facial asymmetry also resolved completely. Hence, the splint was discarded, and exercise sessions reduced.
Photographs of the child and data recorded after each follow-up showed the effectiveness of rehabilitation techniques in reducing above-mentioned impairments in this case of CMT [Table 2] and [Figure 3].
| Discussion | | |
This case study showed amalgamation of the multidisciplinary approaches such as surgical intervention, exercise therapy, splintage, play, and occupation-based rehabilitation in resolving deformities over a period of 7-month postsurgery against the mean treatment duration between 3.8 and 9 months in the previous studies.[2],[6],[8],[10]
Lateral flexion deformity (20° to right side) was corrected by the end of 7 months, and rotation deformity (15° to left side) was corrected by the end of 1 month. This improvement could be attributed to factors such as surgery, customized splint, and stretching exercises, as stated by Krishna et al.,[2] in their study emphasizing on indigenously designed customized static progressive splint in the correction of the head tilt. Their study failed to improve facial asymmetry but achieved remarkable improvement in neck functions. In contrast to their result on facial asymmetry, this case report showed complete correction of mild flattening on the right side of the cheek within 7 months along with a normal cervical range of motion [Figure 3]. These findings are in line with the study of Ekici et al.,[1] which stated that any facial asymmetry could be prevented by surgery and rehabilitation before 6 years of age. The study also revealed that manual stretching exercise was effective in 95% of the Z-plasty cases. One more study by Cheng and Tang[9] also reported a high success rate in the manual stretching method delivered by a skilled therapist in the conservative treatment of CMT.
| Conclusion | | |
This case study signifies the effectiveness of occupational therapy in reducing cervical lateral flexion and rotation deformity (head tilt), improvement in the range of motion of cervical lateral flexion, rotation, and correction in mild facial asymmetry in a 5-year-old female child with CMT.
Patient Perspective
Child and her mother were very much satisfied with the functional and cosmetic results of the neck. She admitted, “I was worried about her looks as she is a girl. But thanks to the team, she looks more beautiful now and can freely move around her neck.”
Informed Consent
The child's mother has provided written informed consent to report this case study in a journal with anonymity.
Declaration of Patient Consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the parent has given his consent for images and other clinical information to be reported in the journal. The child's parent understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Acknowledgment
Sincere gratitude to Dr. Bharti Kulkarni Madam (Pediatric surgeon) for her constant support. Dr. Shilpshree Palsule Madam for her guidance in fabricating the torticollis splint. My family, teachers, friends, and students.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
| References | | |
| 1. | Ekici N, Kizilay A, Akarcay M, Firat Y. Congenital muscular torticollis in older children: Treated with Z-plasty technique. J Craniofac Surg 2014;25:1867-1869.  |
| 2. | Krishna P, Chetan H, Namrata S, Manoj S. Congenital muscular torticollis: Rehabilitation with a customized appliance. JPO 2013;25:89-92. |
| 3. | Do TT. Congenital muscular torticollis: Current concepts and review of treatment. Curr Opin Pediatr 2006;18:26-29. |
| 4. | Shim JS, Jang HP. Operative treatment of congenital torticollis. J Bone Joint Surg Br 2008;90:934-9. |
| 5. | Canale ST, Griffin DW, Hubbard CN. Congenital muscular torticollis. A long-term follow-up. J Bone Joint Surg Am 1982;64:810-8166. |
| 6. | Cheng JC, Tang SP. Outcome of surgical treatment of congenital muscular torticollis. Clin Orthop Relat Res 1999;362:190-200. |
| 7. | Kaplan SL, Coulter C, Sargent B. Physical therapy management of congenital muscular torticollis: A 2018 evidence-based clinical practice guideline from the APTA Academy of Pediatric Physical Therapy. Pediatr Phys Ther 2018;30:240-290. |
| 8. | Jung AY, Kang EY, Lee SH, Nam DH, Cheon JH, Kim HJ. Factors affecting rehabilitation outcome of congenital muscular torticollis. J Korean Acad Rehabil Med 2010;34:643-649. |
| 9. | Cheng JC, Wong MW, Tang SP, Chen TM, Shum SL, Wong EM. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am 2001;83:679-687. |
| 10. | Lee KS, Chung EJ, Lee BH. A study on asymmetry in infants with congenital muscular torticollis according to head rotation. J Phys Ther Sci 2017;29:48-52. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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